Rheumatic fever

Synonyms :  

Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs,

Acute rheumatic fever is an autoallergic disease triggered by infection with specific strains of Streptococcus pyogenes (group A b-haemolytic streptococci) which express antigens cross-reactive with those on human connective tissue. Abnormal humoral and cell-mediated autoimmune response is responsible for the damage found in different tissues. 

It usually affects children or teenagers (5-15 years of age), and there is a definite family variation in susceptibility. This disease can develop only as a sequel to pharyngeal infection by group A b-haemolytic streptococci, but only 3% of those with this type of infection will acquire rheumatic fever. Streptococcal skin infections (e.g., impetigo) do not progress to acute rheumatic fever, although both skin and pharyngeal infections can cause acute glomerulonephritis.

Clinical features:  < BACK TO TOP >

       Nonspecific manifestations such as fever, lymphadenopathy, generalised aches, nausea, vomiting, abdominal pain are frequent, but they occur in other conditions.

       The major specific manifestations are:

acute arthritis

carditis

neurological features (Sydenham’s chorea)

skin changes (erythema marginatum and subcutaneous nodules).

       The arthritis of rheumatic fever (sometimes called acute rheumatism, but not to be confused with rheumatoid arthritis) is an acute painful inflammation of one or several joints.

       Characteristically the arthritis moves from joint to joint (so called migratory polyarthralgia).

       The joints most affected include ankles, knees, elbows, wrists and shoulders, and there is pain, tenderness and redness, and sometimes an effusion in affected joints.

       There is commonly, but not invariably, a history of sore throat 2-4 weeks before the onset of joint symptoms.

       Erythema marginatum occurs in 10-20% of children with rheumatic fever, in form of red macules (blotches) which fade in the centre but remain red at the edges; the resulting red rings or “margins?may coalesce or overlap.

       Subcutaneous nodules are rarely observed and they appear as firm painless nodules best felt over bones or tendons.

       Carditis is the most important manifestation of rheumatic fever; it presents as palpitations, chest pain (usually due to pericarditis) or breathlessness (pulmonary congestion).

       There is usually a tachycardia and often cardiac enlargement.

       Heart murmurs are common although sometimes difficult to detect; soft diastolic murmur is due to mild aortic regurgitation, presystolic murmur is due to mitral stenosis (nodules forming on the mitral valve leaflets).

       Cardiac failure may result either from impaired function of ventricular muscle or from mitral or aortic incompetence caused by valve damage.

       Sydenham’s chorea (Saint Vitus’s dance) occurs several months after acute arthritis in only 3% of all patients, and it is thought to be due to antibodies against basal ganglia.

       It is characterised by sudden, jerky, aimless, involuntary movements of face, tongue and upper extremities, which disappear with sleep, decrease with resting and increase with emotional stress and attempted voluntary movement.

       Voluntary movements are abrupt with impaired coordination, and the patient may appear clumsy.

       It is more common in girls than in boys, but in both spontaneous recovery is usual (although prolonged 3-12 months), and there are no permanent neurologic sequelae.

Diagnosis:  < BACK TO TOP >

       Evidence of a systemic illness:

fever, leukocytosis, raised ESR and C-reactive protein are usual but non-specific.

       Evidence of preceding streptococcal infection:

Culture of group A b-haemolytic streptococci from a throat swab is positive in only a minority by the time rheumatic fever is clinically manifest.

Rapid tests for detection of streptococci in the throat are also available and can be done in few minutes.

Antistreptotysin O antibodies (ASO titre), antideoxyribonuclease B and antihyaluronidase antibodies are useful evidence of recent streptococcal infection, especially if a rising titre can be shown.

       Evidence of carditis:

The chest X-ray may show cardiac enlargement or pulmonary congestion.

ECG changes include first degree heart block (prolongation of PR interval), T wave inversion and reduction in QRS voltages.

Echocardiography is useful for showing cardiac dilation and valve abnormalities.

       Because the diagnosis of acute rheumatic fever is essentially clinical, the Jones criteria have been proposed to simplify this process.

A diagnosis of rheumatic fever is likely in the presence of two major manifestations, or one major and two minor manifestations, plus evidence of previous streptococcal infection.

Major manifestations: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.

Minor manifestations: fever, arthralgia, previous rheumatic fever, raised ESR, first degree or second degree AV block.

Management  < BACK TO TOP >

       Bed-rest is important during the acute phase of rheumatic fever; in patients who have had carditis, it is traditional to continue to bed-rest for 2-6 weeks after ESR and temperature have returned to normal.

       Aspirin in large regular doses is effective in providing symptomatic relief of arthritis, other NSAIDs such as naproxen or ibuprofen may also be used.

       Aspirin should be continued until the ESR has fallen, and then gradually discontinued.

       Corticosteroids (prednisolone or prednisone) produce more rapid symptomatic relief than aspirin, and are preferable in cases with severe arthritis or carditis. However there is no evidence that the long-term effects are superior.

       Penicillin antibiotics are administered to eradicate a streptococcal infection.

       Subsequent prophylaxis is introduced by giving monthly injections of penicillin for the first year, and after that with oral penicillins until the patient reaches the age of 20 (many authors recommend only few years of prophylaxis).

       Cardiac failure should be treated as required; valve replacement may be necessary for severe acute mitral or aortic incompetence.

       Chronic rheumatic heart disease (usually mitral stenosis) can develop as a consequence of severe acute rheumatic fever, especially if it recurs later due to ineffective prevention.

       Treatment of chorea consists of low doses of benzodiazepines or antipsychotic drugs, but only if there is significant movement disorder.

Prognosis  < BACK TO TOP >

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Nutrition < BACK TO TOP >

Nutrition that alleviate or prevent Rheumatic fever :-
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Herbs < BACK TO TOP >

Herbs that alleviate or prevent Rheumatic fever :-
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